HospitalInspections.org

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


12:30 p.m. penetrations in the 2 hour fire barrier wall (3rd floor) were found above the ceiling next to room 223.

1:30 p.m. unprotected pentrations located directly above the fire rated doors and the ceiling
at the 2 hour fire barrier that separates maternity suite from rehab area.



35163

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director on 12/14/15 and 12/15/15 the following was found:

1. On third floor, there were penetrations in the 2 hour fire wall (both sides) with no fire stopping material present.

2. There was evidence of polyurethane spray foam used to seal penetrations.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:

11:45 on 12-15-2015 a canopy attached to the building oustside near the portable MRI machine; the roof covering is exposed and unprotected. The roof covering is required to meet NFPA 256

While surveying the facility on 12/14-15/2015 with the Director of operation, maintenance director and surveyor 35163 this inspector did observe at approximately 11:50 a.m.

Openings in the corridor walls at the wellness check-in counter and check-out counter.

Openings in the wellness check-in counter measure 6"x9" @ 54" off the finish floor and 14" x 5" @ 34 " off the finish floor.

Window opening at the wellness check-out counter measures 24" x 36" @ 3' off the finished floor.

All openings are greater than the allowed 20" square and two of the openings (6x9 and 24x36) are greater than half the room height off the floor.


10:45 on 12-15-2015 penetration in corridor wall into the data room shall be sealed to resist the passage of smoke; vent cut into the corridor wall shall be removed.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately

11:35 p.m.Mail room door propped open; 3rd floor (Patient floor) next to the elevator at the end of the corridor.

1:45p.m. the Medical records room door in the open position held open with a foot peg.


10:32 on 12-15-2015 door striker missing on janitor closet door located on the first floor near Dietary.

11:27 a.m. on 12-15-2015 foot hold open device was found holding an X-ray room door open.






35163

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. The director of wellness/rehab office had a "flipdown" door hold open device was holding the door open.

2. Clinical support managers office located on the third floor, had a "flipdown" door hold open device was holding the door open.

3. Second floor double doors near surgical suite/day surgery area did not properly close.

4. Dietary services storage room had wooden "door wedge" holding the door open preventing the door from self closing and positive latching.

5. X-ray door #1 had a "flipdown" door hold open device was holding the door open.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately

1:22 p.m.Penetrations in the smoke barrier wall on the third floor next to the exit stairwell and between Rehab and Maternity.

8:50 a.m. on 12-15-2015 penetrations were found above the ceiling in both smoke barrier walls located near the nurses stion in ICU.


9:30 on 12-15-2015 penetrations in the smoke barrier wall were found above the ceiling near room 125.

While surveying the facility on 12-14-2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:

1:15p.m. the distance measured between smoke barrier doors located in the Rehab area corridor was greater than what is required for proper operation of the doors. Greater than 1/8" was measured between the two smoke barrier doors.

8:40 a.m. on 12-15-2015 in the ICU department near the nurses station both sets of smoke barrier doors were measured in accordance with 19.3.7.6 for proper operation of the doors. Approximately 3/8" was measured between each pair on both sets of smoke barrier doors.

9:01 a.m. on 12-15-2015 set of smoke barrier doors in medical surgical unit near nurses station. A 3/4" gap at the bootom of the doors is revaeled. When the doors are fully closed the doors rest evenly at the top on the door jamb but not at the bottom. It appears that one of the two doors has warped.

9:23 a.m. the distance measured between smoke barrier doors located near room 125 was greater than what is required for proper operation of the doors. Greater than 1/8" was measured between the two smoke barrier doors.

11:15a.m. on 12-15-2015 the distance measured between smoke barrier doors located near Mamography area was found to be greater than what is required for proper operation of the doors. Greater than 1/8" was measured between the two smoke barrier doors.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:

1:30 p.m.room 308 over 50 square feet and being used for storage with no self-closing device on the door.

9:05 a.m. on 12-15-2015 room 206 over 50 square feet and being used as storage with no self-closing device on the door.

10:03 on 12-15-2015 penetrations through the one hour floor/ceiling assembly located in the boiler room.

1:45 p.m. on 12-15-2015 in the OR suite 2 storage room doors next to OR room #1 required to have self-closing doors.

1:50 p.m. on 12-15-2015 in the OR suite the dirty utility room requires a self-closing door.


















35163


Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Third floor shower room that was converted into a storage room, did not self close (no self closing device) and positive latch.

2. Staff breakroom located within the OT/PT area on the third floor, did not self close (no self closing device) and positive latch.

3. Third floor PT/OT administrative office has a door (that opens to a mechanical room/space) and did not self close and positive latch

4. Third floor O.B. changing room did not self close (no self closing device) and positive latch.

5. second floor anesthesia office/storage room did not self close (no self closing device) and positive latch

6. First floor double doors that enter soiled linen storage/pick up area did not self close (no self closing device) and positive latch.

7. First floor decontamination/storage room located near the emergency room did not self close (no self closing device) and positive latch

8. Cardio-equipment room did not self close (no self closing device) and positive latch

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. There were penetrations on all levels of the exit stair towers that did not have fire stopping material present and would not prevent the passage of smoke or fire.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Third floor exit corridor had OT/PT equipment stored in egress path; which did not allow for means of egress to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

2. Exit stair towers had wiring (data cables) that was not connected to items serving the space.

3. Second floor near anesthesia office and elevator there were 5-cleaning carts, 2-linen/laundry carts stored in the exit corridor .

4. Main entrance doors (sliding doors with emergency breakaway) foyer had storage that would impede the opening of the doors during an emergency.

5. Emergency room/ambulance entrance/exit doors (sliding doors with emergency breakaway) foyer had storage that would impede the opening of the doors during an emergency.

6. 2. Medical gas piping (oxygen, medical air and vacuum) located within the exit stairwell (O/B stairwell).

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


11:36 a.m. storage of laundry carts, wheel chairs, clean linen racks, etc... located in the corridor third floor near elevator and mailroom.


8:23 a.m. on 12-15-2015 storage located in the corridor next to the nurses staion second floor.

9:44 a.m. on 12-15-2015 storage (Utility carts, hampers, clean linen racks, etc...) in corridor first floor across from Men and ladies locker rooms.

9:55 a.m. on 12-15-2015 carts blocking exterior exit near loading dock area.

While surveying the facility on 12-14-2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately 10:50 a.m.

No record of fire drill being conducted for the first shift in the first quarter of 2015.

No record of fire drill being conducted for the second shift in the second quarter of 2015.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


10:50 a.m. on 12-15-2015 ED doctors sleeping room requires horn/strobe unit and smoke detector.


35163

Based on records review and interview with maintenance director on 12/14/15 and 12/15/15 surveyor 35163 the following was found:

1. Fire alarm audio /visual aids had not been tested/inspected during the last six quarters that the fire alarm testing company had been to to facility, according to documentation that was provided. Upon interview with the maintenance director he verified that he had requested the testing company not perform the test of the audio visual aids and that he would "check them" during monthly fire drills, but he could not provide any documentation that he was trained/licensed to perform these test or that they had been done. There is a total of approximately 80 audio visual aids in the facility.

2. The magnetic door hold open devices that are connected to the fire alarm system had not been tested/inspected during the last six quarters, according to documentation that was provided. Upon interview with the maintenance director he verified that the devices had not been tested/inspected.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Data cables located on all levels of the exit stair towers were attached to sprinkler piping.

2. Third floor medical records office storage room had items stored within less than 18" of the sprinkler head.

3. Second floor pharmacy area had items stored within less than 18" of the sprinkler head.

4. First floor O/B stair tower had a missing sprinkler pipe hanger

5. The main sprinkler riser located on the first floor near dietary services, did not have a hydraulic information plate

6. O/R dirty utility room had items stored within less than 18" of the sprinkler head.

7. O/R storage room had items stored within less than 18" of the sprinkler head.

8. Third floor janitor/maintenance room had a rubber drain line attached to sprinkler piping.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


8:30 a.m. on 12-15-2015 sprinkler escutcheon cap missing in the corridor of the ICU department.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Kitchen used for staff breakroom located on third floor OT/PT area does not have a commercial cooking hood w/ suppression.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


10:50 a.m. on 12-15-2015 a portable heating device was found in ED doctors sleeping area.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director on 12/14/15 and 12/15/15 the following was found:

1. There were several items throughout the facility that did not have documentation that they were flame retardant from the manufacturer or that they had been treated will a flame retardant spray


2. Patient room #201 had a shower curtain that did not have a tag that is was flame retardant from the manufacturer and no documentation could be provided.

While surveying the facility on 12-14-2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately 11:41 a.m.


Green drapes hung within the diabetes education room with no markings indicating that they meet NFPA 701.

Room 223 (3rd floor) drapes covering storage shelves required to be treated or shall meet NFPA 701.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


11:1 5a.m. Oxygen tank found unsecured on a stretcher in the ambulance vestibule area.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Local alarm panel for piped in medical gases located in the operating room area, does not have labeling that indicates what area it serves.

2. X-Ray zone valve box missing label for gas identification and what area it serves.

3. Exterior emergency oxygen supply connection was blocked and not accessible or visible.

4. Second floor ICU area had a zone valve box (serving tele 1-4 & ICU-1-4) that had improper and missing medical gas labeling

5. Above the ceiling in the area of patient room 210, the medical gas piping had improper labeling (wrong color coding).

6. Medical Surgical zone valve box was missing a label.

7. O/B procedure room had improperly labeled medical air outlet.

8. No area alarm panel could be locted for the area serving 2nd floor recovery/ med. surg.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. O/B procedure room-above ceiling had two electrical junction boxes that were missing covers and had exposed wiring

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Alcohol sanitizing station were located in the exit stair towers.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


12:30 p.m. penetrations in the 2 hour fire barrier wall (3rd floor) were found above the ceiling next to room 223.

1:30 p.m. unprotected pentrations located directly above the fire rated doors and the ceiling
at the 2 hour fire barrier that separates maternity suite from rehab area.



35163

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director on 12/14/15 and 12/15/15 the following was found:

1. On third floor, there were penetrations in the 2 hour fire wall (both sides) with no fire stopping material present.

2. There was evidence of polyurethane spray foam used to seal penetrations.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:

11:45 on 12-15-2015 a canopy attached to the building oustside near the portable MRI machine; the roof covering is exposed and unprotected. The roof covering is required to meet NFPA 256

While surveying the facility on 12/14-15/2015 with the Director of operation, maintenance director and surveyor 35163 this inspector did observe at approximately 11:50 a.m.

Openings in the corridor walls at the wellness check-in counter and check-out counter.

Openings in the wellness check-in counter measure 6"x9" @ 54" off the finish floor and 14" x 5" @ 34 " off the finish floor.

Window opening at the wellness check-out counter measures 24" x 36" @ 3' off the finished floor.

All openings are greater than the allowed 20" square and two of the openings (6x9 and 24x36) are greater than half the room height off the floor.


10:45 on 12-15-2015 penetration in corridor wall into the data room shall be sealed to resist the passage of smoke; vent cut into the corridor wall shall be removed.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately

11:35 p.m.Mail room door propped open; 3rd floor (Patient floor) next to the elevator at the end of the corridor.

1:45p.m. the Medical records room door in the open position held open with a foot peg.


10:32 on 12-15-2015 door striker missing on janitor closet door located on the first floor near Dietary.

11:27 a.m. on 12-15-2015 foot hold open device was found holding an X-ray room door open.






35163

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. The director of wellness/rehab office had a "flipdown" door hold open device was holding the door open.

2. Clinical support managers office located on the third floor, had a "flipdown" door hold open device was holding the door open.

3. Second floor double doors near surgical suite/day surgery area did not properly close.

4. Dietary services storage room had wooden "door wedge" holding the door open preventing the door from self closing and positive latching.

5. X-ray door #1 had a "flipdown" door hold open device was holding the door open.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately

1:22 p.m.Penetrations in the smoke barrier wall on the third floor next to the exit stairwell and between Rehab and Maternity.

8:50 a.m. on 12-15-2015 penetrations were found above the ceiling in both smoke barrier walls located near the nurses stion in ICU.


9:30 on 12-15-2015 penetrations in the smoke barrier wall were found above the ceiling near room 125.

While surveying the facility on 12-14-2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:

1:15p.m. the distance measured between smoke barrier doors located in the Rehab area corridor was greater than what is required for proper operation of the doors. Greater than 1/8" was measured between the two smoke barrier doors.

8:40 a.m. on 12-15-2015 in the ICU department near the nurses station both sets of smoke barrier doors were measured in accordance with 19.3.7.6 for proper operation of the doors. Approximately 3/8" was measured between each pair on both sets of smoke barrier doors.

9:01 a.m. on 12-15-2015 set of smoke barrier doors in medical surgical unit near nurses station. A 3/4" gap at the bootom of the doors is revaeled. When the doors are fully closed the doors rest evenly at the top on the door jamb but not at the bottom. It appears that one of the two doors has warped.

9:23 a.m. the distance measured between smoke barrier doors located near room 125 was greater than what is required for proper operation of the doors. Greater than 1/8" was measured between the two smoke barrier doors.

11:15a.m. on 12-15-2015 the distance measured between smoke barrier doors located near Mamography area was found to be greater than what is required for proper operation of the doors. Greater than 1/8" was measured between the two smoke barrier doors.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:

1:30 p.m.room 308 over 50 square feet and being used for storage with no self-closing device on the door.

9:05 a.m. on 12-15-2015 room 206 over 50 square feet and being used as storage with no self-closing device on the door.

10:03 on 12-15-2015 penetrations through the one hour floor/ceiling assembly located in the boiler room.

1:45 p.m. on 12-15-2015 in the OR suite 2 storage room doors next to OR room #1 required to have self-closing doors.

1:50 p.m. on 12-15-2015 in the OR suite the dirty utility room requires a self-closing door.


















35163


Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Third floor shower room that was converted into a storage room, did not self close (no self closing device) and positive latch.

2. Staff breakroom located within the OT/PT area on the third floor, did not self close (no self closing device) and positive latch.

3. Third floor PT/OT administrative office has a door (that opens to a mechanical room/space) and did not self close and positive latch

4. Third floor O.B. changing room did not self close (no self closing device) and positive latch.

5. second floor anesthesia office/storage room did not self close (no self closing device) and positive latch

6. First floor double doors that enter soiled linen storage/pick up area did not self close (no self closing device) and positive latch.

7. First floor decontamination/storage room located near the emergency room did not self close (no self closing device) and positive latch

8. Cardio-equipment room did not self close (no self closing device) and positive latch

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. There were penetrations on all levels of the exit stair towers that did not have fire stopping material present and would not prevent the passage of smoke or fire.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Third floor exit corridor had OT/PT equipment stored in egress path; which did not allow for means of egress to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

2. Exit stair towers had wiring (data cables) that was not connected to items serving the space.

3. Second floor near anesthesia office and elevator there were 5-cleaning carts, 2-linen/laundry carts stored in the exit corridor .

4. Main entrance doors (sliding doors with emergency breakaway) foyer had storage that would impede the opening of the doors during an emergency.

5. Emergency room/ambulance entrance/exit doors (sliding doors with emergency breakaway) foyer had storage that would impede the opening of the doors during an emergency.

6. 2. Medical gas piping (oxygen, medical air and vacuum) located within the exit stairwell (O/B stairwell).

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


11:36 a.m. storage of laundry carts, wheel chairs, clean linen racks, etc... located in the corridor third floor near elevator and mailroom.


8:23 a.m. on 12-15-2015 storage located in the corridor next to the nurses staion second floor.

9:44 a.m. on 12-15-2015 storage (Utility carts, hampers, clean linen racks, etc...) in corridor first floor across from Men and ladies locker rooms.

9:55 a.m. on 12-15-2015 carts blocking exterior exit near loading dock area.

While surveying the facility on 12-14-2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately 10:50 a.m.

No record of fire drill being conducted for the first shift in the first quarter of 2015.

No record of fire drill being conducted for the second shift in the second quarter of 2015.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


10:50 a.m. on 12-15-2015 ED doctors sleeping room requires horn/strobe unit and smoke detector.


35163

Based on records review and interview with maintenance director on 12/14/15 and 12/15/15 surveyor 35163 the following was found:

1. Fire alarm audio /visual aids had not been tested/inspected during the last six quarters that the fire alarm testing company had been to to facility, according to documentation that was provided. Upon interview with the maintenance director he verified that he had requested the testing company not perform the test of the audio visual aids and that he would "check them" during monthly fire drills, but he could not provide any documentation that he was trained/licensed to perform these test or that they had been done. There is a total of approximately 80 audio visual aids in the facility.

2. The magnetic door hold open devices that are connected to the fire alarm system had not been tested/inspected during the last six quarters, according to documentation that was provided. Upon interview with the maintenance director he verified that the devices had not been tested/inspected.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Data cables located on all levels of the exit stair towers were attached to sprinkler piping.

2. Third floor medical records office storage room had items stored within less than 18" of the sprinkler head.

3. Second floor pharmacy area had items stored within less than 18" of the sprinkler head.

4. First floor O/B stair tower had a missing sprinkler pipe hanger

5. The main sprinkler riser located on the first floor near dietary services, did not have a hydraulic information plate

6. O/R dirty utility room had items stored within less than 18" of the sprinkler head.

7. O/R storage room had items stored within less than 18" of the sprinkler head.

8. Third floor janitor/maintenance room had a rubber drain line attached to sprinkler piping.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


8:30 a.m. on 12-15-2015 sprinkler escutcheon cap missing in the corridor of the ICU department.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Kitchen used for staff breakroom located on third floor OT/PT area does not have a commercial cooking hood w/ suppression.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


10:50 a.m. on 12-15-2015 a portable heating device was found in ED doctors sleeping area.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director on 12/14/15 and 12/15/15 the following was found:

1. There were several items throughout the facility that did not have documentation that they were flame retardant from the manufacturer or that they had been treated will a flame retardant spray


2. Patient room #201 had a shower curtain that did not have a tag that is was flame retardant from the manufacturer and no documentation could be provided.

While surveying the facility on 12-14-2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately 11:41 a.m.


Green drapes hung within the diabetes education room with no markings indicating that they meet NFPA 701.

Room 223 (3rd floor) drapes covering storage shelves required to be treated or shall meet NFPA 701.

While surveying the facility on 12/14-15/2015 with the Director of operations, maintenance director and surveyor 35163 this inspector did observe at approximately:


11:1 5a.m. Oxygen tank found unsecured on a stretcher in the ambulance vestibule area.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Local alarm panel for piped in medical gases located in the operating room area, does not have labeling that indicates what area it serves.

2. X-Ray zone valve box missing label for gas identification and what area it serves.

3. Exterior emergency oxygen supply connection was blocked and not accessible or visible.

4. Second floor ICU area had a zone valve box (serving tele 1-4 & ICU-1-4) that had improper and missing medical gas labeling

5. Above the ceiling in the area of patient room 210, the medical gas piping had improper labeling (wrong color coding).

6. Medical Surgical zone valve box was missing a label.

7. O/B procedure room had improperly labeled medical air outlet.

8. No area alarm panel could be locted for the area serving 2nd floor recovery/ med. surg.

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. O/B procedure room-above ceiling had two electrical junction boxes that were missing covers and had exposed wiring

Based on observation of the surveyor 35163, 34673, in the presence of the maintenance director and director of operations on 12/14/15 and 12/15/15 the following was found:

1. Alcohol sanitizing station were located in the exit stair towers.